Treatment of obstructive sleep apnea (osa)

ABSTRACT

A system for treatment of obstructive sleep apnea (OSA) is described. The system includes an introducer needle having an elongated body. The introducer needle is configured to create an opening in a tongue of a patient for implantation of a lead for treating OSA. One or more electrically conductive areas are located on the elongated body. A medical device is configured to deliver a stimulation signal via the introducer needle through the one or more electrically conductive areas to the tongue of the patient to stimulate one or more motor points of a protrusor muscle within the tongue of the patient.

This application is a divisional of U.S. patent application Ser. No.16/752,023, filed Jan. 24, 2020, the entire content of which isincorporated herein by reference.

TECHNICAL FIELD

This disclosure relates to medical device systems and, moreparticularly, to medical device systems for delivery of electricalstimulation therapy.

BACKGROUND

Obstructive sleep apnea (OSA), which encompasses apnea and hypopnea, isa disorder in which breathing may be irregularly and repeatedly stoppedand started during sleep, resulting in disrupted sleep and reduced bloodoxygen levels. Muscles in a patient's throat intermittently relaxthereby allowing soft tissues of the throat to obstruct the upper airwaywhile sleeping and cause OSA. In patients with a smaller than normalairway, airflow into the upper airway can be obstructed by the tongue orsoft pallet moving to the back of the throat and covering the airway.Loss of air flow also causes unusual inter-thoracic pressure as a persontries to breathe with a blocked airway. Lack of adequate levels ofoxygen during sleep can contribute to abnormal heart rhythms, heartattack, heart failure, high blood pressure, stroke, memory problems, andincreased accidents during the day due to inadequate sleep.Additionally, loss of sleep occurs when a person is awakened during anapneic episode.

SUMMARY

The devices, systems, and techniques of this disclosure generally relateto an implantable medical device (IMD) system and methods for therapyfor obstructive sleep apnea (OSA) but can be extended to address otherpatient symptoms and disorders. With OSA, a patient's tongue may relaxduring sleep and block the patient's airway. Some example techniques toaddress OSA include electrically stimulating one or both hypoglossalnerves and/or motor points in the tongue of the patient. In response tothe electrical stimulation, the hypoglossal nerve(s) causes protrusormuscles (e.g., genioglossus and geniohyoid muscles) to contract and movethe tongue forward, thereby opening the airway. In some examples, inresponse to stimulating at the motor points of the protrusor muscles(e.g., a location where an axon of the hypoglossal nerve terminates at amuscle fiber), the protrusor muscles may contract to move the tongueforward, thereby opening the airway.

To stimulate the hypoglossal nerve(s) and/or motor points, a medicaldevice outputs electrical stimulation therapy via one or more electrodeson one or more implanted leads to cause the tongue to move forward. Amedical professional can implant the one or more leads into the tongueof the patient. The one or more implanted leads each include one or moreelectrodes coupled to the medical device (e.g., an implantable orexternal medical device that delivers electrical stimulation via one ormore electrodes on the lead).

With lead placement in the tongue, there may be issues related to howand where to place a lead to provide effective therapy. This disclosuredescribes example techniques for lead structures and/or lead placementthat may overcome one or more issues. Although the example techniquesare described with respect to lead placement in the tongue for treatingOSA, the example techniques should not be considered to be limited tolead placement in the tongue or limited to treating OSA.

In an example, the disclosure describes a system for treatment of OSA.The system includes an introducer needle having an elongated body. Theintroducer needle is configured to create an opening in a tongue of apatient for implantation of a lead for treating OSA. One or moreelectrically conductive areas are located on the elongated body. Amedical device is configured to deliver a stimulation signal via theintroducer needle through the one or more electrically conductive areasto the tongue of the patient to stimulate one or more motor points of aprotrusor muscle within the tongue of the patient.

In an example, the disclosure describes a system for treatment of OSA.The system includes an introducer needle having an elongated body. Theintroducer needle is configured to create an opening in a tongue of apatent for implantation of a lead for treating OSA. One or moreelectrically conductive areas are located on the elongated body. Anintroducer sheath is able to be placed within the opening created by theintroducer needle. The introducer sheath may have one or moreperforations that align with one or more electrodes of the lead insertedinto the introducer sheath. One or more medical devices are configuredto deliver a stimulation signal via the introducer needle through theone or more electrically conductive areas to the tongue of the patientto stimulate one or more motor points of a protrusor muscle within thetongue of the patient. The one or more medical devices are furtherconfigured to deliver the stimulation signal with the one or moreelectrodes of the lead that is inserted into the introducer sheath andthrough the one or more perforations of the introducer sheath to thetongue of the patient.

In one example, the disclosure describes a method for treatment of OSA.The method includes inserting an introducer needle through tissue near achin of a patient and through a tongue of the patient to create anopening in a tongue of a patent for implantation of a lead for treatingOSA. The introducer needle has an elongated body. One or moreelectrically conductive areas are located on the elongated body. Themethod further includes controlling a medical device to deliver astimulation signal via the introducer needle through the one or moreelectrically conductive areas to the tongue of the patient to stimulateone or more motor points of a protrusor muscle within the tongue of thepatient.

The details of one or more aspects of the disclosure are set forth inthe accompanying drawings and the description below. Other features,objects, and advantages of the techniques described in this disclosurewill be apparent from the description and drawings, and from the claims.

BRIEF DESCRIPTION OF DRAWINGS

FIG. 1 is a conceptual diagram of an implantable medical device (IMD)system for delivering obstructive sleep apnea (OSA) therapy.

FIG. 2 is a conceptual diagram of a lead used for OSA therapy accordingto one or more examples of this disclosure.

FIG. 3 is a conceptual diagram illustrating example locations of motorpoints where stimulation for OSA therapy may be delivered.

FIG. 4 is a block diagram illustrating example configurations ofimplantable medical devices (IMDs) which may be utilized in the systemof FIG. 1.

FIG. 5 is a block diagram illustrating an example configuration of anexternal programmer.

FIG. 6A-6C are conceptual diagrams illustrating a lead and an exampleintroducer needle which may be utilized in the system of FIG. 1.

FIG. 7A-7C are conceptual diagrams illustrating the lead of FIG. 6A andanother example introducer needle which may be utilized in the system ofFIG. 1.

FIG. 8A-8D are conceptual diagrams illustrating another lead, anotherexample introducer needle, and an example introducer sheath which may beutilized in the system of FIG. 1.

FIG. 9 is a flowchart illustrating an example of lead implantation.

FIG. 10 is a flowchart illustrating another example of leadimplantation.

DETAILED DESCRIPTION

Medical devices, systems, and techniques for delivering electricalstimulation to the protrusor muscles of the tongue for the treatment ofobstructive sleep apnea (OSA) are described in this disclosure.Electrical stimulation is delivered to cause the tongue of a patient toenter a protruded state, during sleep, to avoid or reduce upper airwayobstruction. As used herein, the term, “protruded state” with regard tothe tongue refers to a position that is moved forward and/or downwardcompared to a non-stimulated position or a relaxed position of thetongue. The protruded state is a state associated with contraction(e.g., via innervation from nerves in response to electricalstimulation) of protrusor muscles of the tongue (also sometimes referredto as “protruder” muscles of the tongue) including the genioglossus andgeniohyoid muscles. A protruded state may be the opposite of a retractedand/or elevated position associated with the contraction of theretractor muscles (e.g., styloglossus and hyoglossus muscles) whichretract and elevate the tongue. Electrical stimulation is delivered tocause the tongue to move (e.g., by depolarizing the nerve(s) thatinnervate the genioglossus and/or geniohyoid muscles) to and maintain aprotruded state. As discussed above, the protruded state may preventcollapse or blockage of, open, or widen the upper airway of a patient toat least partially maintain or increase airflow (e.g., promoteunrestricted airflow or at least reduced restriction of airflow duringbreathing).

A surgeon implants one or more leads that each include one or electrodesinto the tongue such that the electrodes are proximate to a hypoglossalnerve and/or motor points (e.g., one or more locations where axons ofthe hypoglossal nerve terminate at respective muscle fibers of theprotrusor muscles). For example, there are two hypoglossal nerves in thetongue of the patient. In one example, one lead may be used to stimulate(e.g., by delivering electrical stimulation through one or moreelectrodes of the lead) one of the two hypoglossal nerves, one lead maybe used to stimulate both hypoglossal nerves, or two leads may be used,where each lead stimulates a respective one of the hypoglossal nerves.Stimulation of either or both hypoglossal nerves of the tongue can causecontraction of the protrusor muscles to reduce the effect of or preventOSA.

There are multiple sets of motor points for each of the protrusormuscles on the left side and the right side. Each motor point mayinnervate one or more muscle fibers of the protrusor muscle. In oneexample, one lead may be used to stimulate motor points for theprotrusor muscles on one side of the tongue, one lead may be used tostimulate motor points for protrusor muscles on both sides of thetongue, or two leads may be used, where each lead stimulates arespective set of motor points for the protrusor muscles on each side.Stimulation of either or both sets of motor points of the tongue cancause contraction of the protrusor muscles to reduce the effect of, orprevent, OSA.

This disclosure describes examples of techniques related to implantationof the one or more leads in the tongue for treatment of OSA. Althoughthe example techniques are described with respect to OSA, the exampletechniques should not be construed as limited to OSA. Rather, theexample techniques described in this disclosure may be applicable tolead implantation for treatment of various conditions, including leadimplantation for treatment of conditions where the lead is implanted ina location other than the tongue.

Open surgeries may be performed to implant the one or more leads in atongue of a patient for treating OSA. However, such open surgeriesrequire dissection of tissue to expose one or more hypoglossal nervesand/or motor points for placement of the one or more leads immediatelyadjacent to or around the hypoglossal nerves and/or motor points in thetongue of the patient, which is relatively invasive and time-consuming.This disclosure describes examples of implant systems and methods forimplanting the one or more leads in the tongue of the patient in amanner that may reduce the invasiveness and duration of the surgeries.

As described in more detail, implant systems may include introducerneedles and medical devices for determining a target treatment site inthe tongue of the patient for implantation of the one or more leads. Theexample introducer needles described in this disclosure may include oneor more electrically conductive areas, and the one or more electricallyconductive areas may be used to deliver stimulation signals. Responsiveto the delivery of the stimulation signals, a surgeon or other medicalprofessional may visually inspect if there is movement of the protrusormuscles. However, in some examples, a medical device may be utilized todetect one or more electrical signals (e.g., electromyography (EMG)signals) that are generated in response to the delivery of thestimulation signals through the introducer needle to determine if thereis activation of the protrusor muscles. The detection of one or moreelectrical signals may be in addition to or instead of visualinspection. The example medical devices described in this disclosure maybe coupled with the example introducer needles, and may generate thestimulation signals, receive the one or more electrical signals detectedby the introducer needles, and output information indicatives of the oneor more electrical signals.

The example techniques described in this disclosure may enable a surgeonto implant one or more leads adjacent to or around one or morehypoglossal nerves and/or motor points in the tongue of a patientwithout dissecting tissue to expose the hypoglossal nerves and/or motorpoints, which minimize access incision, shorten recovery time for thepatient, and reduce risk for misplacement of the leads. For example, bystimulating locations within the tongue with the introducer needle, thesurgeon may determine an appropriate location for implantation of thelead before the implantation of the lead. Moreover, in some examples,the electrically conductive areas on the introducer needle may alignwith the electrodes of the lead (e.g., the spacing and shape of theelectrically conductive areas on the introducer needle is same asspacing and shape of the electrodes on the lead). In such cases, thesurgeon may be able to replicate the electrical field that will begenerated by the lead post lead placement with the electricallyconductive areas of the introducer needle to determine the efficacy ofthe treatment before lead placement.

FIG. 1 is a conceptual diagram of a medical system for delivering OSAtherapy. In system 10, implantable medical device (IMD) 16 and lead 20are implanted in patient 14. IMD 16 includes housing 15 enclosingcircuitry of IMD 16. In some examples, IMD 16 includes connectorassembly 17, which is hermetically sealed to housing 15 and includes oneor more connector bores for receiving a proximal end of at least onemedical electrical lead 20 used for delivering OSA therapy. Although onelead 20 is illustrated in FIG. 1, there may be one or more leads 20 towhich IMD 16 is coupled.

Lead 20 may include a flexible, elongate lead body 22, also calledelongated member 22, that extends from lead proximal end 24 to leaddistal end 26. As illustrated, lead 20 includes one or more electrodes30 that are carried along a lead distal portion adjacent lead distal end26 and are configured for insertion within the protrusor muscles 42A,42B, and 46 of tongue 40. As one example, the genioglossus muscleincludes oblique compartment 42A and horizontal compartment 42B. In thisdisclosure, the genioglossus muscle is referred to as protrusor muscle42. Protrusor muscle 46 is an example of the geniohyoid muscle.

As illustrated, distal end 26 of lead 20 includes one or more electrodes30. Proximal end 24 of lead 20 includes one or more electrical contactsto connect to connector assembly 17. Lead 20 also includes conductorssuch as coils or wires that connect respective electrodes 30 torespective electrical contacts at proximal end 24 of lead 20.

While protrusor muscles 42 and 46 are described, the example techniquesdescribed in this disclosure are not limited to stimulating protrusormuscles 42 and 46. Also, FIG. 1 illustrates one set of protrusor muscles42 and 46 (e.g., on a first side of tongue 40). The other side of tongue40 also includes protrusor muscles. For instance, a left side of tongue40 includes a first set of protrusor muscles 42 and 46, and a right sideof tongue 40 includes a second set of protrusor muscles.

In some examples, a surgeon may implant one or more leads 20 such thatone or more electrodes 30 are implanted within soft tissue, such asmusculature, proximate to medial branches of one or both hypoglossalnerves. In some examples, one or more electrodes 30 may be approximately5 mm (e.g., 2 mm to 8 mm) from a major trunk of the hypoglossal nerve.In some examples, one or more electrodes 30 may be placed in an area ofprotrusor muscles 42 and 46 that include motor points, where each nerveaxon terminates in the muscle (also called the neuro-muscular junction).The motor points are not at one location but spread out in the protrusormuscles. Leads 20 may be implanted such that one or more electrodes 30may be generally in the area of the motor points (e.g., such that themotor points are within 1 to 10 mm from one or more electrodes 30).Examples of motor points for protrusor muscles 42 and 46 are illustratedin more detail with respect to FIG. 3.

Tongue 40 includes a distal end (e.g., tip of tongue 40), and electrodes30 may be implanted proximate to root 49 of tongue 40. The surgeon mayimplant one or more leads 20 such that one or more electrodes areimplanted proximate to root 49 of tongue 40, as illustrated in FIG. 1.For example, the location for stimulation for the genioglossus muscle 42may be approximately 30 mm (e.g., 25 mm to 35 mm) from the Symphysis ofthe jaw (e.g., where the genioglossus and hypoglossal muscles insert).The location for stimulation for the geniohyoid muscle 46 may beapproximately 40 mm (e.g., 35 mm to 45 mm) from the Symphysis. For boththe genioglossus muscle 42 and the geniohyoid muscle 44, the locationfor stimulation may be approximately 11 mm (e.g., 7 mm to 15 mm) lateralto the midline on both the right and left sides of tongue 40 forstimulating respective hypoglossal nerves. In some examples, rather thanstimulating hypoglossal nerves, the examples described in thisdisclosure may be configured for stimulating the motor points, asdescribed in more detail with respect to FIG. 3. Stimulating the motorpoints may result in indirect activation of the hypoglossal nerve, butmay generally be stimulating at a different location than directstimulation to the hypoglossal nerve. As a result, in some examples,simulation of one or more motor points may result in more preciseactivation of muscle fibers than may be possible with stimulation of thehypoglossal nerve itself.

One or more electrodes 30 of lead 20 may be ring electrodes, segmentedelectrodes, partial ring electrodes, or any suitable electrodeconfiguration. Ring electrodes extend 360 degrees around thecircumference of the lead body of lead 20. Segmented and partial ringelectrodes each extend along an arc less than 360 degrees (e.g., 90-120degrees) around the outer circumference of the lead body of lead 20. Inthis manner, multiple segmented electrodes may be disposed around theperimeter of lead 20 at the same axial position of the lead. In someexamples, segmented electrodes may be useful for targeting differentfibers of the same or different nerves at respective circumferentialpositions with respect to the lead to generate different physiologicaleffects (e.g., therapeutic effects), permitting stimulation to beoriented directionally. In some examples, lead 20 may be, at least inpart, paddle-shaped (e.g., a “paddle” lead), and may include an array ofelectrodes arranged as contacts or pads on a common surface, which mayor may not be substantially flat and planar.

As described above, in some examples, electrodes 30 are within themusculature of tongue 40. Accordingly, one or more electrodes 30 may be“intramuscular electrodes.” Intramuscular electrodes may be differentthan other electrodes that are placed on or along a nerve trunk orbranch, such as a cuff electrode, used to directly stimulate the nervetrunk or branch. The example techniques described in this disclosure arenot limited to intramuscular electrodes and may be extendable toelectrodes placed closer to a nerve trunk or branch of the hypoglossalnerve(s). Also, in some examples, rather than one or more electrodes 30being “intramuscular electrodes,” one or more electrodes 30 may beimplanted in connective tissue or other soft tissue proximate to thehypoglossal nerve.

In some examples, lead 20 may be configured for advancement through thesoft tissue, which may include the protrusor muscle tissue, to anchorelectrodes 30 in proximity to the hypoglossal nerve(s) that innervateprotrusor muscles 42 and/or 46 and/or motor points that connect axons ofhypoglossal nerve(s) to respective muscle fibers of protrusor muscles 42and/or 46. However, in some examples, lead 20 may be configured foradvancement through vasculature of tongue 40. As one example, a surgeonmay implant lead 20 in the lingual veins near the hypoglossal nervethrough venous access in the subclavian vein. In such examples, one ormore electrodes 30 may be “intravascular electrodes.”

As described above, electrical stimulation therapy generated by IMD 16and delivered via one or more electrodes 30 may activate protrusormuscles 42 and 46 to move tongue 40 forward, for instance, to promote areduction in obstruction or narrowing of the upper airway 48 duringsleep. As used herein, the term “activated” with regard to theelectrical stimulation of protrusor muscles 42 and 46 refers toelectrical stimulation that causes depolarization or an action potentialof the cells of the nerve (e.g., hypoglossal nerve(s)) or stimulation atthe neuro-muscular junction between the nerve and the protrusor muscles(e.g., at the motor points) innervating protrusor muscles 42 and 46 andmotor points and subsequent depolarization and mechanical contraction ofthe protrusor muscle cells of protrusor muscles 42 and 46. In someexamples, protrusor muscles 42 and 46 may be activated directly by theelectrical stimulation therapy.

Protrusor muscles 42 and/or 46, on a first side of tongue 40 (e.g., theleft or right side of tongue 40), may be activated by a medial branch ofa first hypoglossal nerve, and the protrusor muscles, on a second sideof tongue 40 (e.g., the other of the left or right side of tongue 40),may be activated by a medial branch of a second hypoglossal nerve. Themedial branch of a hypoglossal nerve may also be referred to as theXIIth cranial nerve. The hyoglossus and styloglossus muscles (not shownin FIG. 1), which cause retraction and elevation of tongue 40, areactivated by a lateral branch of the hypoglossal nerve.

One or more electrodes 30 may be used to deliver bilateral or unilateralstimulation to protrusor muscles 42 and 46 via the medial branch of thehypoglossal nerve or branches of the hypoglossal nerve (e.g., such as atthe motor point where a terminal branch of the hypoglossal nerveinterfaces with respective muscle fibers of protrusor muscles 42 and/or46). For example, one or more electrodes 30 may be coupled to outputcircuitry of IMD 16 to enable delivery of electrical stimulation pulsesin a manner that selectively activates the right and left protrusormuscles (e.g., in a periodic, cyclical or alternating pattern) to avoidmuscle fatigue while maintaining upper airway patency. Additionally, oralternatively, IMD 16 may deliver electrical stimulation to selectivelyactivate protrusor muscles 42 and/or 46 or portions of protrusor muscles42 and/or 46 during unilateral stimulation of the left or rightprotrusor muscles.

In some examples, one lead 20 may be implanted such that one or more ofelectrodes 30 deliver electrical stimulation to stimulate the lefthypoglossal nerve or motor points of protrusor muscles on the left sideof tongue, and therefore cause the left protrusor muscles to activate.In such examples, the electrical stimulation from one or more electrodes30 may not be of sufficient amplitude to stimulate the right hypoglossalnerve or motor points of protrusor muscles on the right side of tongueand cause the right protrusor muscles to activate. In some examples, onelead 20 may be implanted such that one or more of electrodes 30 deliverelectrical stimulation to stimulate the right hypoglossal nerve or motorpoints of protrusor muscles on the right side of tongue, and thereforecause the right protrusor muscles to activate. In such examples, theelectrical stimulation from one or more electrodes 30 may not be ofsufficient amplitude to stimulate the left hypoglossal nerve or motorpoints of protrusor muscles on the left side of tongue and cause theleft protrusor muscles to activate. Accordingly, in some examples, twoleads like lead 20 may be implanted to stimulate each of the left andright hypoglossal nerves and/or motor points of respective protrusormuscles on the left and right side of tongue 40.

In some examples, one lead 20 may be implanted substantially in themiddle (e.g., center) of tongue 40. In such examples, one or moreelectrodes 30 may deliver electrical stimulation to both hypoglossalnerves or motor points of both muscles on the both sides of tongue 40,causing both hypoglossal nerves or motor points to activate respectiveleft and right protrusor muscles. It may be possible to utilize currentsteering and field shaping techniques such that one or more electrodes30 deliver first electrical stimulation that stimulates the lefthypoglossal nerve or motor points of protrusor muscles on the left sideof tongue 40 with little to no stimulation of the right hypoglossalnerve or motor points of protrusor muscles on the right side of tongue40, and then one or more electrodes 30 deliver second electricalstimulation that stimulates the right hypoglossal nerve or motor pointsof protrusor muscles on the right side of tongue with little to nostimulation of the left hypoglossal nerve or motor points of protrusormuscles on the left side of tongue. In examples where two leads likelead 20 are utilized, each lead may alternate delivery of stimulation torespective hypoglossal nerves or motor points. In this way, IMD 16 maystimulate one hypoglossal nerve or one set of motor points and then theother hypoglossal nerve or another set of motor points, which can reducemuscle fatigue.

For instance, continuous stimulation may cause protrusor muscles to becontinuously in a protruded state. This continuous contraction may causeprotrusor muscles 42 and/or 46 to fatigue. In such cases, due tofatigue, the stimulation may not cause protrusor muscles 42 and/or 46 tomaintain a protruded state (or higher intensity of the electricalstimulation may be needed to cause protrusor muscles 42 and/or 46 toremain in the protruded state). By stimulating one set of protrusormuscles (e.g., left or right), a second set (e.g., other of left orright) of protrusor muscles can be at rest. Stimulation may thenalternate to stimulate the protrusor muscles that were at rest andthereby maintain protrusion of tongue 40, while permitting the protrusormuscles 42 and/or 46 that were previously activated to rest. Hence, bycycling between alternate stimulation of the left and right protrusormuscles, tongue 40 can remain in the protruded state, while one of thefirst or second set of protrusor muscles is at rest.

In some examples, one lead 20 may be implanted laterally or diagonallyacross tongue 40 such that some of electrodes 30 on lead 20 can be usedto stimulate the left hypoglossal nerve and/or motor points of theprotrusor muscles on the left side of tongue 40 and some of electrodes30 on the same lead 20 can be used to stimulate the right hypoglossalnerve and/or motor points of the protrusor muscles on the right side oftongue 40. In such examples, IMD 16 may selectively deliver electricalstimulation to a first hypoglossal nerve and/or first motor points ofthe protrusor muscles on the a first side of tongue 40 via a first setof one or more electrodes 30, and then deliver electrical stimulation toa second hypoglossal nerve and/or/or second set of motor points of theprotrusor muscles on a second side of tongue 40 via a second set of oneor more electrodes 30. This may be another way in which to reduce musclefatigue.

Lead proximal end 24 includes a connector (not shown in FIG. 1) that maybe coupled to connector assembly 17 of IMD 16 to provide electricalconnection between circuitry enclosed by the housing 15 of IMD 16. Leadbody 22 encloses electrical conductors extending from each of one ormore electrodes 30 to the proximal connector at proximal end 24 toprovide electrical connection between output circuitry of IMD 16 and theelectrodes 30.

There may be various ways in which lead 20 is implanted in patient 14.As one example, a surgeon may insert a needle (also called introducerneedle) through the lower part of the jaw and in tongue 40 starting fromthe back of tongue 40. The surgeon may insert the needle until a distaltip of the needle reaches a point at or adjacent to the tip of tongue40, angling the needle to be extend proximate to the hypoglossal nerve(e.g., left or right hypoglossal nerve). In some examples, the needlemay include one or more electrically conductive areas (e.g., one or moreelectrodes) at the distal end, and the surgeon may cause the one or moreelectrically conductive areas of the needle to output electricalstimulation (e.g., in the form of controlled current pulses orcontrolled voltage pulses), which in turn causes a physiologicalresponse such as activation of protrusor muscles 42 and/or 46 andprotrusion of tongue 40. The surgeon may adjust the location of theneedle based on the physiological response to determine a location intongue 40 that provides effective treatment. Using a needle withstimulating electrodes is not necessary in every example.

Once the needle is in place, the surgeon may insert a guidewire (orsimply “guide”) through the needle and anchor the guidewire (e.g., withtines on the guidewire) to tissue of tongue 40. Then, the surgeon mayremove the needle leaving behind the guidewire.

The surgeon may place an introducer sheath, which may or may not includea dilator, over the guidewire through the opening created by theintroducer needle. In some examples, the introducer sheath mayoptionally include one or more electrodes that the surgeon can use totest stimulation of tongue 40 to ensure that lead 20 will be located inthe correct location, relative to the target nerve tissue. Once theintroducer sheath is in place, the surgeon may remove the guidewire. Insome examples, the introducer sheath may be flexible or curved to easeplacement of the introducer sheath in patient 14. The guidewire and theintroducer sheath may help placement of lead 20 adjacent to or aroundthe hypoglossal nerve. For example, using the guidewire and theintroducer sheath may enable a lead having a diameter equal to or largerthan the diameter of the introducer needle to the inserted in theopening created by the introducer needle.

In some examples, rather than or in addition to the introducer sheathhaving one or more electrodes, the introducer sheath may include one ormore perforations. The one or more perforations may align withelectrodes 30. Prior to placement of lead 20, the surgeon may place lead20 into the introducer sheath such that electrodes 30 align with theperforations of the introducer sheath. A medical device may outputstimulation signals through electrodes 30 and the perforations of theintroducer sheath to stimulate the hypoglossal nerve and/or one or moremotor points of the protrusor muscle within tongue 40. In this way, iffurther refinement is needed to determine the lead placement for lead20, the surgeon may adjust the location of lead 20 in response to one ormore electrical signal detected by electrodes 30 and through theperforation of the introducer sheath.

In some examples, the surgeon may directly insert lead 20 through theintroducer needle without using the introducer sheath and the guidewire.In such examples, the introducer needle may be appropriately sized toreceive lead 20 and may perform operations similar to those of theintroducer sheath described above.

The surgeon may prepare lead 20 for insertion. In some examples, theremay be an additional sheath placed over lead 20 that holds fixationmember(s), such as those described with respect to FIG. 2, in place. Useof such an additional sheath is not necessary in all examples. Forinstance, the introducer sheath may be configured to hold the fixationmember(s) in place. Because lead 20 may be highly flexible, in someexamples, the surgeon may place a stylet through lead 20 to provide somerigidity and allow lead 20 to traverse through tongue 40 under a pushingforce. Use of a stylet may not be necessary in all examples.

The surgeon may put lead 20 through the introducer such that one or moreelectrodes 30 are proximate to the hypoglossal nerve (e.g., such thatdistal end 26 is near tip of tongue as one non-limiting example).Electrodes 30 may be proximate to the hypoglossal nerve and/or motorpoints of the protrusor muscles due to the needle creating an openingnear the hypoglossal nerve and/or motor points of the protrusor muscle.The surgeon may then tunnel proximal end 24 of lead 20 back to aconnection with IMD 16.

In this manner, the surgeon may implant one lead 20. In examples wheretwo or more leads are implanted, the surgeon may perform steps similarto those described above.

The above describes some example techniques for lead placement, and theexamples described in this disclosure should not be considered limitedto such examples of lead placement. Moreover, in some examples, thesurgeon may use imaging techniques, such as fluoroscopy, duringimplantation to verify proper placement of lead 20, the introducerneedle, and/or the introducer sheath.

FIG. 1 illustrates the location of IMD 16 as being within or proximateto the neck of patient 14. However, IMD 16 may be implanted in variousother locations. As one example, the surgeon may implant IMD 16 in theleft or right pectoral region. For instance, the surgeon may plan onimplanting IMD 16 in the left pectoral region unless another medicaldevice is already implanted in the left pectoral region. If anothermedical device is already implanted in the left pectoral region, thesurgeon may then implant IMD 16 in the right pectoral region. There mayinclude other locations where the surgeon may implant IMD 16, such asthe back of patient 14. The example techniques are not limited to anyparticular implant location of IMD 16.

In accordance with one or more examples described in this disclosure,system 10 is an implant system for utilizing lead 20 in tongue 40 fortreatment of OSA. In some example, the system may be configured suchthat substantial dissection is not required to expose one or morehypoglossal nerves and/or one or more motor points of the protrusormuscle within tongue 40 for placement of the lead. This disclosuredescribes examples of system 10 configured for placement of lead 20 in away that minimizes access incisions for placement of lead 20.

In some situations, it may be desirable to include multiple electrodeson lead 20 to achieve desired physiological effects (e.g., therapeuticeffects). For example, to achieve the desired effect, multipleelectrodes may be used to target different fibers of the same nerve(e.g., target one or more motor points of the protrusor muscle withintongue 40). In such cases, determining the locations of the differentfibers or motor points one at a time is time-consuming and may causenerve injury. In some examples, system 10 may enable a surgeon toidentify the locations of different fibers or motor points of theprotrusor muscles in such a manner to shorten the surgical time andreduce the risk of nerve injury.

As described above, system 10 is an implant system for implanting lead20 adjacent to or around one or more hypoglossal nerves and/or motorpoints without open surgery, so that lead 20 may be implanted tostimulate the nerves with minimal impact to patient 14. There may becertain unique challenges associated with implanting lead 20 adjacent toor around the hypoglossal nerves and/or the one or more motor points ofthe protrusor muscle in tongue 40 without open surgery. As one example,without performing an open surgery to expose the hypoglossal nervesand/or motor points, there are difficulties with localizing andaccessing the hypoglossal nerves and/or motor points.

To identify the location of a hypoglossal nerve and/or a motor pointwithout performing an open surgery, system 10 may include an introducerneedle for creating an opening in the tongue of the patient forimplantation of lead 20 and a medical device for delivering stimulationsignals through the introducer needle to the tongue of the patient tostimulate the hypoglossal nerve and/or the motor point. The same medicaldevice or possibly another medical device may further receive electricalsignals from lead 20, where the electrical signals (e.g., EMG signals)are generated from a muscle movement in response to the stimulationsignals. As illustrated in FIG. 1, the medical device may be animplantable medical device (e.g., IMD 16) implanted near the neck ofpatient 14. Hence, IMD 16 may be utilized for chronic (i.e., long-term)treatment of OSA. However, in some examples, during the implantation oflead 20 or determining location for implanting lead 20, a trialstimulator (e.g., external medical device) may be used to deliverstimulation to the introducer needle or through lead 20 when lead 20 iswithin the introducer sheath. Accordingly, the medical device may be anexternal medical device coupled to the introducer needle for deliveringstimulation signals. In some examples, a first medical device may beutilized to stimulate the electrically conducive areas on the introducerneedle, and a second different medical device may be utilized tostimulate electrodes 30 when lead 20 is within the introducer sheath. Insome examples, the first medical device and the second medical devicemay be the same medical device. It should be noted that IMD 16 may alsobe used as a trial stimulator, and the techniques are not limited to anexternal medical device.

As described below in further detail, the introducer needle may beinserted through tongue 40 to a proximate position of the hypoglossalnerve and/or the motor point in tongue 40. The introducer needle mayinclude an elongated body having one or more electrically conductiveareas for delivering OSA therapies. The introducer needle may couplewith a medical device to deliver one or more stimulation signals fromthe medical device to the tongue of the patient. The one or moreelectrically conductive areas (e.g., two electrically conductive areas,three electrically conductive areas, or four electrically conductiveareas, etc.) of the elongated body may deliver the one or morestimulation signals to tongue 40 to stimulate the hypoglossal nerveand/or the motor point to innervate one or more of a genioglossal orgeniohyoid muscle. The one or more electrically conductive areas of theintroducer needle may also detect one or more electrical signals thatare generated based on the movements of the genioglossal and/orgeniohyoid muscle.

For example, after insertion of the introducer needle, the introducerneedle may be coupled with a medical device to deliver a stimulationsignal through the one or more electrically conductive areas of theintroducer needle to stimulate a hypoglossal nerve and/or one or moremotor points of the protrusor muscle within tongue 40. In response tothe stimulation signal, the hypoglossal nerve may innervate protrusormuscles 42 or 46 or the activation of the one or more motor points maycause protrusor muscles 42 or 46 to protrude, and one or moreelectrically conductive areas of the introducer needle may detectelectrical signals (e.g., EMG signals) that represents the movement ofprotrusor muscles 42 or 46. In such examples, the medical device mayreceive the electrical signals detected by the one or more electricallyconductive areas of the introducer needle and output informationindicative of the electrical signals. In some examples, the medicaldevice that outputs the stimulation signal may be different than themedical device that receives the electrical signals detected by theelectrically conductive areas on the introducer needle, or the medicaldevice that outputs the stimulation signal may be the same as themedical device that receives the electrical signals detected by theelectrically conductive areas on the introducer needle. Based on theoutput information indicative of the electrical signals, a surgeon maydetermine a target treatment site for placement of lead 20.

Accordingly, system 10 is an example of an implant system for implantinglead 20 for treatments of OSA. System 10 includes an introducer needlethat has an elongated body (e.g., the needle body).

The elongated body may be a malleable elongated body so that a surgeoncan bend the desired shape for properly introducing lead 20. In someexamples, the elongated body may be steerable so the surgeon can alignlead 20 in a proper configuration intraoperatively. Having steerabilityin the elongated body may make it easier for surgeons to deploy lead 20alongside and in proximity to a hypoglossal nerve and/or a motor pointin tongue 40 of patient 14.

The elongated body includes one or more electrically conductive areasfor delivering stimulation signals that can protrude tongue 40 fordetermining stimulation location for OSA therapies. The one or moreelectrically conductive areas of the introducer needle are located at adistal end of the elongated body. At the distal end of the introducerneedle should not be interpreted to be limited mean that there is anelectrically conductive area exactly at the distal end, although havingan electrically conductive area exactly at the distal end is possible.Rather, “at the distal end” means that the one or more electricallyconductive areas are proximate to the distal end of the introducerneedle, including possibly being exactly at the distal end of theintroducer needle. As one example, multiple electrically conductiveareas may be longitudinally located relative to each other at the sameaxial position of the introducer needle. As another example, multipleelectrically conductive areas may be circumferentially located relativeto each other along an outer perimeter of the elongated body of theintroducer needle in a direction orthogonal to the axial of theintroducer needle.

System 10, along with the introducer needle, also includes a medicaldevice for delivering stimulation signals via the introducer needlethrough the one or more electrically conductive areas to tongue 40 ofpatient 14 to stimulate a hypoglossal nerve and/or a motor point intongue 40 of patient 14. The medical device may also receive one or moreelectrical signals detected by the introducer needle and outputinformation indicative of the one or more electrical signals. Forexample, the medical device may receive an EMG signal that measures anelectrical current generated from a muscle contraction in response tothe stimulation signal.

For instance, a surgeon may insert the introducer needle in tongue 40 ofpatient 14 such that the one or more electrically conductive areas ofthe introducer needle are pushed through tissue near a chin of thepatient and through the tongue proximate to the hypoglossal nerve and/orthe motor point of a protrusor muscle within tongue 40. After insertingthe introducer needle, the surgeon may control the medical device todeliver a stimulation signal via the introducer needle through the oneor more electrically conductive areas to tongue 40 of patient 14 tostimulate the hypoglossal nerve and/or the motor point in tongue 40 ofpatient 14. The surgeon may also control the medical device (same ordifferent medical device) to receive electrical signals detected by theintroducer needle and output information indicative of the one or moreelectrical signals on a display device. The surgeon may then determine atarget treatment site based on the output information indicative of theone or more electrical signals.

In some examples, system 10 may further include an introducer sheathhaving one or more perforations. The one or more perforations of theintroducer sheath are aligned with the one or more electricallyconductive areas of the introducer needle. The one or more perforationsof the introducer sheath are further aligned with electrodes 30 of lead20.

In some examples, lead 20 may have a relatively large diameter. Forexample, lead 20 may have a diameter equal to or larger than thediameter of the introducer needle so that lead 20 may not be inserted inthe lumen of the elongated body of the introducer needle.

For instance, instead of insert lead 20 in the lumen of the elongatedbody of the introducer needle, the surgeon may insert a guidewire in thelumen of the elongated body, remove the introducer needle while leavethe guidewire in tongue 40 of patient 14, and slide the introducersheath over the guidewire so that the one or more perforations of theintroducer sheath reach the hypoglossal nerve and/or the motor point intongue 40 of patient 14.

After inserting the introducer sheath in and through the opening createdby the introducer needle, the surgeon may remove the guidewire andinsert lead 20 in the introducer sheath so that electrodes 30 of lead 20are aligned with the one or more perforations of the introducer sheath.The surgeon may also control a medical device to output stimulationsignals through electrodes 30 and the perforations of the introducersheath to stimulate the hypoglossal nerve and/or the motor point. Inthis way, a lead having a diameter equal to or larger than the diameterof the introducer needle may be inserted in and through the openingcreated by the introducer needle.

FIG. 2 is a conceptual diagram of lead 20 used for OSA therapy accordingto one or more examples. For instance, FIG. 2 illustrates distal portion28 of lead 20, where distal portion 28 of lead 20 may form part of lead20 that is implanted in tongue 40, as described above. Lead 20 mayinclude one or more electrodes 30, and FIG. 2 shows lead 20 with fourelectrodes 30A, 30B, 30C, and 30D (collectively referred to as“electrodes 30”) spaced apart longitudinally along lead body 22. Leadbody 22 is an example of the elongated member of lead 20. For instance,lead body 22 and the elongated member of lead 20 are the same.

Lead body 22 (e.g., elongated member of lead 20) may be a flexible leadbody through which insulated electrical conductors extend to respectiveelectrodes 30. The distal most electrode 30A may be adjacent orproximate to lead distal end 26. Each of electrodes 30 may be spacedproximally from the respective adjacent one of electrodes 30 byrespective interelectrode distances 34, 35 and 36.

The electrical conductors that extend to respective electrodes 30 fromproximal contacts at proximal end 24 may be arranged as a plurality ofcoils. The coils may increase the flexibility of lead 20 so that lead 20can bend at the distal end. In some examples, the coils may be exposedalong the locations of electrodes 30 such that the coils form electrodes30. Rather than electrodes 30 being pad electrodes or ring electrodes,the coils form electrodes 30 and, in this way, electrodes 30 arebendable, providing additional flexibility. In such examples, electrodes30 are coil electrodes.

In some examples, each one of electrodes 30 may have equivalentelectrode lengths 31 (e.g., longitudinal extend of electrodes 30 alonglead body 22). Lengths 31 may be approximately 3 mm, but less than 3 mmlengths are possible. However, electrodes 30 may have electrode lengths31 that are different from each other in order (e.g., to optimizeplacement of the electrodes 30 or the resulting electrical field ofstimulation relative to targeted stimulation sites corresponding to leftand right hypoglossal nerves or branches of hypoglossal nerves and/ormotor points of protrusor muscles 42 and/or 46).

Spacing 34, 35, and 36 are shown to be approximately equal in FIG. 2.However, in other examples, the interelectrode spacings 34, 35, and 36may be different from each other (e.g., in order to optimize placementof electrodes 30 relative to the targeted stimulation sites). Spacing34, 35, and 36 may be approximately 3 mm but less than 3 mm spacing ispossible. In some examples, for a bipolar configuration, electrodes 30Aand 30B form an anode and cathode pair for delivering bipolarstimulation in one portion of the protrusor muscles 42 and/or 46 (e.g.,either the left or right protrusor muscles or a proximal and/or distalportion of portion of the protrusor muscles). Electrodes 30C and 30D mayform a second anode and cathode pair for delivering bipolar stimulationin a different portion of protrusor muscles 42 and/or 46 (e.g., theother of the left or right portions or the other of the proximal ordistal portions). Accordingly, the interelectrode spacing 35 between thetwo bipolar pairs 30A, 30B and 30C, 30D may be different than theinterelectrode spacing 34 and 36 between the anode and cathode withineach bipolar pair 30A, 30B and 30C, 30D.

In some examples, for a unipolar configuration, housing 15 of IMD 16 mayinclude an electrode that functions as cathode, and part of the anodeand cathode pair with one of electrodes 30. In some examples, housing 15itself may function as the cathode of an anode, cathode pair, with oneof electrodes 30 forming the anode. Housing 15 may be anode in someexamples.

In one example, the total distance D1 encompassed by electrodes 30 alongthe distal portion 28 of lead body 22 may be between approximately 20and 30 millimeters. In one example, the total distance D1 is betweenapproximately 20 and 22 millimeters. However, as an alternative, thedistances may be shorter. As one example, the distance from distalportion 28 to one or more fixation members 32 may be approximately 10millimeters to ensure that at least one of the one or more fixationmembers 32 is implanted within tongue 40.

The interelectrode spacings 34 and 36 within a proximal electrode pair30C, 30D and a distal electrode pair 30A, 30B, respectively, may be in arange of approximately 2 to 5 millimeters in some examples. Theinterelectrode spacing 35 separating the distal and proximal pairs 30A,30B and 30C, 30D may be greater than the interelectrode spacings 34 and36. For example, the interelectrode spacing 35 may be in a range ofapproximately 4 to 6 millimeters in some examples. In one example, eachof electrodes 30 has an electrode length 31 of approximately 3 mm, andeach of interelectrode spacings 34, 35 and 36 is approximately 3 mm.

In FIG. 2, each of electrodes 30 is a circumferential ring electrodewhich may be uniform in diameter with lead body 22. As described above,electrodes 30 may include other types of electrodes such as a tipelectrode, a helical electrode, a coil electrode, as described above,segmented electrodes, a button electrode as examples. For instance, thedistal most electrode 30A may be provided as a tip electrode at the leaddistal end 26 with the remaining three electrodes 30B, 30C, and 30Dbeing ring electrodes. In some examples, when electrode 30A ispositioned at the distal end 26, electrode 30A may be a helicalelectrode configured to screw into the muscle tissue at the implant siteto additionally serve as a fixation member for anchoring the distalportion 28 of lead 20 at the targeted therapy delivery site. In someexamples, one or more of electrodes 30 may be a hook electrode or barbedelectrode to provide active fixation of the distal portion 28 of lead 20at the therapy delivery site.

Lead 20 may include one or more fixation members 32 for minimizing thelikelihood of lead migration. Fixation member 32 may include multiplesets of tines which engage the surrounding tissue when lead distalportion 28 is positioned at the target therapy delivery site. The tinesof fixation member 32 may extend radially outward and proximally at anangle relative to the longitudinal axis of lead body 22 to prevent orreduce retraction of lead body 22. For instance, the tines may includesprings that in an uncompressed state extend the tines outwards. Tinesof fixation member 32 may be collapsible against lead body 22 when lead20 is held within the confines of a lead delivery tool (e.g., anintroducer needle or an introducer sheath) used to deploy lead distalportion 28 at the target implant site. Upon removal of the lead deliverytool, the tines of fixation member 32 may spread to a normally extendedposition (e.g., due to the spring bias) to engage with surroundingtissue and resist proximal and lateral migration of lead body 22. Forinstance, the tines may be normally biased to the extended position butretracted against the introducer sheath for implantation. When theintroducer sheath is removed, the tines extend outward to theiruncompressed state. Examples of the tines for fixation members 32include tines 31 of FIG. 1. In some examples, fixation member 32 mayadditionally or alternatively include one or more hooks, barbs, helices,or other fixation mechanisms extending from one or more longitudinallocations along lead body 22 and/or lead distal end 26.

In some examples, the tines, when deployed, may be forward facing and/orbackward facing. Forward facing means that the portion of the tines thatare more proximate to proximal end 24 spread out when deployed. Forinstance, the tine has a connection point on lead body 22 and a free armof the tine that extends away from the lead body 22, and the portion ofthe free arm that is more proximate to proximal end 24 extends. Backwardfacing means that the portion of the tines that are more proximate todistal end 26 spread out when deployed. For instance, the tine has aconnection point on lead body 22 and a free arm of the tine that extendsaway from the lead body 22, and the portion of the free arm that is moreproximate to distal end 26 extends. Having both forward and backwardfacing tines may reduce lateral and proximal migration.

Fixation members 32 may partially or wholly engage one or more ofprotrusor muscles 42 and/or 46 and/or other muscles below tongue 40,and/or other soft tissues of the neck (e.g., fat and connective tissue),when proximal end of lead body 20 is tunneled to an implant pocket ofIMD 16. In some examples, fixation member 32 may include one or morefixation mechanisms located at other locations, including at orproximate to distal end 26, between electrodes 30, or otherwise moredistally or more proximally than the location shown in FIG. 2.

The implant pocket of IMD 16 may be in a pectoral region of patient 14.Lead body 22 may include proximal connectors that engage with connectorassembly 17 of IMD 16. Accordingly, the length of the elongated leadbody 22 from distal portion 28 to the lead proximal end 24 may beselected to extend from a target therapy delivery site in protrusormuscles 42 and/or 46 to a location in the pectoral region where IMD 16is implanted. The length of lead body 22 (e.g., elongated member) may beup to 10 cm or up to 20 cm as examples but may generally be 25 cm orless, though longer or shorter lead body lengths may be used dependingon the anatomy and size of patient 14.

FIG. 3 is a conceptual diagram illustrating example locations of motorpoints where stimulation for OSA therapy may be delivered. FIG. 3illustrates jaw 50 of patient 14, where patient 14 is in a supineposition and jaw 50 of patient 14 is viewed from an inferior location ofpatient 14. For instance, FIG. 3 illustrates symphysis 51 and hyoid bone52. In the example illustrated in FIG. 3, the line interconnectingsymphysis 51 and hyoid bone 52 may be considered as a y-axis along themidline of tongue 40. FIG. 3 also illustrates intergonial distance 53between the two gonia of patient 14, where the gonia is a point on eachside of the lower jaw 50 at the mandibular angle. Intergonial distance53 may be along the x-axis of tongue 40.

FIG. 3 illustrates motor points 54A and 54B and motor points 55A and55B. Motor points 54A may be motor points for the right genioglossusmuscle, and motor points 54B may be motor points for the leftgenioglossus muscle. Motor points 55A may be motor points for the rightgeniohyoid muscle, and motor points 55B may be motor points for the leftgeniohyoid muscle. Motor points 54A and 54B and motor points 55A and 55Bmay genericize the motor points for each muscle for purposes ofillustration. There may be additional motor points and/or motor pointsat different locations for each muscle.

In one or more examples, lead 20 and/or one or more electrodes 30 may beimplanted proximate to motor points 54A, 54B, 55A, or 55B forstimulating at motor points 54A, 54B, 55A, and/or 55B. For instance, inexamples where two leads are implanted, a first lead and its electrodesmay be implanted proximate to motor points 54A and/or 55A and a secondlead and its electrodes may be implanted proximate to motor points 54Band/or 55B. In one or more examples, electrodes 30 may be approximately1 mm to 10 mm from respective motor points 54A, 54B, 55A, or 55B.

A hypoglossal nerve (e.g., on the left or right side of tongue 40)initially is a trunk of nerves fibers called axons. The axons of thehypoglossal nerve branch out. For example, the trunk of hypoglossalnerve includes multiple sets of axons including a first set of axons,and the first set of axons branch out from the trunk of the hypoglossalnerve. The first set of axons include multiple groups of axons includinga first group of axons, and the first group of axons branch out from thefirst set of axons, and so forth. The locations where the branched-outaxons interface with respective muscle fibers of protrusor muscles 42and/or 46 (e.g., genioglossus and/or geniohyoid muscle) are referred toas motor points.

For instance, a branch of the hypoglossal nerve that interfaces (e.g.,connects at the neuro-muscular junction) with the muscle fiber isreferred to as a terminal branch, and the end of the terminal branch isa motor point. The length of a terminal branch may be approximately 10mm from the hypoglossal nerve to the genioglossal or geniohyoid muscles.In some examples, there may be approximately an average of 1.5 terminalbranches with a standard deviation of +0.7 for the right geniohyoidmuscle, an average of 4.8 terminal branches with a standard deviation of+1.4 for the right genioglossus muscle, an average of 2.0 terminalbranches with a standard deviation of +0.9 for the left geniohyoidmuscle, and an average of 5.1 terminal branches with a standarddeviation of +1.9 for the left genioglossus muscle.

There may be possible advantages with stimulating at motor points 54A,54B, 55A, or 55B, as compared to some other techniques. For instance,some techniques utilize cuff electrodes or stimulate at the hypoglossalnerve. Due to the different bifurcation patterns, placing a cuffelectrode around the hypoglossal nerve, or generally attaching anelectrode to the hypoglossal nerve can be challenging. Also, where cuffelectrodes or electrodes that attach to the hypoglossal nerve are used,implanting electrodes around or at each of the hypoglossal nervesrequires multiple surgical entry points to attached to both hypoglossalnerves. Moreover, utilizing cuff electrodes or electrodes that attach tothe hypoglossal nerves can possibly negatively impact the nerve bytugging, stretching, or otherwise causing irritation. Accordingly,utilizing lead 20 and electrodes 30 that are implanted proximate to themotor points may be beneficial (e.g., less surgery to implant and lessimpact on the nerve) as compared to techniques where cuff electrodes orelectrodes implanted on the hypoglossal nerve are utilized.

Furthermore, stimulating at motor points 54A, 54B, 55A, and/or 55B, suchas at the bifurcation point of a motor neuron that attach to musclefibers, may provide advantages such as for better control of musclemovement. Because motor points 54A, 54B, 55A, and 55B are spatiallydistributed, by stimulating motor points 54A, 54B, 55A, and/or 55B, theamount of the genioglossus and geniohyoid muscle that is beingstimulated can be controlled. Also, stimulating at motor points 54A,54B, 55A, and/or 55B may allow for more gentle muscle activation. Forinstance, when stimulation is provided near the trunk of the hypoglossalnerve, even stimulation signal with relatively small amplitude can causethe genioglossus and/or geniohyoid muscle to fully protrude (e.g., thereis high loop gain where small stimulation amplitudes cause large muscleprotrusion). Fine tuning of how much to protrude the genioglossus and/orgeniohyoid muscle may not be available when stimulating at a trunk ofthe hypoglossal nerve. However, there may be lower loop gain stimulatingat motor points 54A, 54B, 55A, and/or 55B. For instance, a stimulationsignal having a lower amplitude may move cause the genioglossus and/orgeniohyoid muscle to protrude a small amount, and a stimulation signalhaving a higher amplitude may move cause the genioglossus and/orgeniohyoid muscle to protrude a higher amount when stimulating at motorpoints 54A, 54B, 55A and/or 55B.

The following are example locations of motor points 54A, 54B, 55A, and55B relative to the midline (x-axis), posterior symphysis 51 (y-axis),and depth (z-axis), where the depth is from the plane formed by theinferior border of symphysis 51 and anterior border of hyoid bone 52.

Motor points 54A may be for the right genioglossus muscle and may belocated at 13.48 mm±3.59 from the x-axis, 31.01 mm±6.96 from the y-axis,and 22.58 mm±3.74 from the z-axis. Motor points 55A may be for the rightgeniohyoid muscle and may be located at 11.74 mm±3.05 from the x-axis,41.81 mm±6.44 from the y-axis, and 16.29 mm+3.40 from the z-axis. Motorpoints 54B may be for the left genioglossus muscle and may be located at9.96 mm±2.24 from the x-axis, 29.62 mm±9.25 from the y-axis, and 21.11mm±4.10 from the z-axis. Motor points 55B may be for the left geniohyoidmuscle and may be located at 11.45 mm±1.65 from the x-axis, 39.63mm±8.03 from the y-axis, and 15.09 mm±2.41 from the z-axis.

FIG. 4 is block diagram illustrating example configurations ofimplantable medical devices (IMDs) which may be utilized in the systemof FIG. 1. As shown in FIG. 4, IMD 16 includes sensing circuitry 56,processing circuitry 57, therapy delivery circuitry 58, switch circuitry59, memory 60, telemetry circuitry 61, and power source 62. IMD 16 mayinclude a greater or fewer number of components. For example, in someexamples, such as examples in which IMD 16 deliver the electricalstimulation in an open-loop manner, IMD 16 may not include sensingcircuitry 56.

Switch circuitry 59 may be configured to, in response to instructionsfrom processing circuitry 57, switch the coupling of electrodes 30between sensing circuitry 56 and therapy delivery circuitry 58. Inexamples where sensing circuitry 56 is not used, switch circuitry 59 maynot be needed. However, even in examples where sensing circuitry 56 isnot used, IMD 16 may include switch circuitry 59 such as to disconnectelectrodes 30 from therapy delivery circuitry 58.

In some examples, therapy delivery circuitry 58 may include a pluralityof regulated current sources or sinks, with each current source or sinkcoupled to one of electrodes 30. In such examples, therapy deliverycircuitry 58 may control each current source or sink and switchingbetween electrodes 30 may not be necessary for therapy delivery sinceeach one of electrodes 30 is individually controllable.

Although not shown in FIG. 3, in some examples, IMD 16 may include oneor more sensors configured to sense posture or position of patient 14.For example, IMD 16 may include accelerometer to determine if patient 14is lying down. Another example of the one or more sensors is a motionsensor, and movement sensed by the motion sensor may indicate if patient14 is having restless sleep, which may be indicative of the onset ofOSA. Additional examples of the sensors include acoustical sensors or amicrophone for detecting vibrations in upper airway 48. Vibrations inupper airway 48 may be indicative of the onset of OSA. In some examples,processing circuitry 57 may control delivery of therapy based oninformation received from the one or more sensors, such as delivery oftherapy after sensing an onset of OSA.

In some examples, electrodes 30 may be configured to senseelectromyogram (EMG) signals. Sensing circuitry 56 may be switchablycoupled to electrodes 30 via switch circuitry 59 to be used as EMGsensing electrodes with electrodes 30 are not being used forstimulation. EMG signals may be used by processing circuitry 57 todetect sleep state and/or low tonal state of protrusor muscles 42 and/or46 for use in delivering electrical stimulation. In some examples,rather than using electrodes 30 or in addition to using electrodes 30,there may be other electrodes or sensors used to sense EMG signals.

In general, IMD 16 may comprise any suitable arrangement of hardware,alone or in combination with software and/or firmware, to perform thetechniques attributed to IMD 16 and processing circuitry 57, therapydelivery circuitry 58, and telemetry circuitry 61 of IMD 16. In variousexamples, IMD 16 may include one or more processors, such as one or moremicroprocessors, digital signal processors (DSPs), application specificintegrated circuits (ASICs), field programmable gate arrays (FPGAs), orany other equivalent integrated or discrete logic circuitry, as well asany combinations of such components.

The various units of IMD 16 may be implemented as fixed-functioncircuits, programmable circuits, or a combination thereof.Fixed-function circuits refer to circuits that provide particularfunctionality, and are preset on the operations that can be performed.Programmable circuits refer to circuits that can be programmed toperform various tasks, and provide flexible functionality in theoperations that can be performed. For instance, programmable circuitsmay execute software or firmware that cause the programmable circuits tooperate in the manner defined by instructions of the software orfirmware. Fixed-function circuits may execute software instructions(e.g., to receive parameters or output parameters), but the types ofoperations that the fixed-function circuits perform are generallyimmutable. In some examples, one or more of the units may be distinctcircuit blocks (fixed-function or programmable), and in some examples,one or more of the units may be integrated circuits.

IMD 16 may include arithmetic logic units (ALUs), elementary functionunits (EFUs), digital circuits, analog circuits, and/or programmablecores, formed from programmable circuits. In examples where theoperations of IMD 16 are performed using software executed by theprogrammable circuits, memory 60 may store the instructions (e.g.,object code) of the software that processing circuitry 57 receives andexecutes, or another memory within IMD 16 (not shown) may store suchinstructions.

IMD 16 also, in various examples, may include a memory 60, such asrandom access memory (RAM), read only memory (ROM), programmable readonly memory (PROM), erasable programmable read only memory (EPROM),electronically erasable programmable read only memory (EEPROM), flashmemory, comprising executable instructions for causing the one or moreprocessors to perform the actions attributed to them. Moreover, althoughsensing circuitry 56, processing circuitry 57, therapy deliverycircuitry 58, switch circuitry 59, and telemetry circuitry 61 aredescribed as separate circuitry, in some examples, sensing circuitry 56,processing circuitry 57, therapy delivery circuitry 58, switch circuitry59, and telemetry circuitry 61 are functionally integrated. In someexamples, sensing circuitry 56, processing circuitry 57, therapydelivery circuitry 58, switch circuitry 59, and telemetry circuitry 61correspond to individual hardware units, such as ASICs, DSPs, FPGAs, orother hardware units.

Memory 60 stores stimulation programs 63 (also called therapy programs63) that specify stimulation parameter values for the electricalstimulation provided by IMD 16. Memory 60 may also store instructionsfor execution by processing circuitry 57, in addition to stimulationprograms 63. Information related to sensed parameters of patient 14(e.g., from sensing circuitry 56 or the one or more sensors of IMD 16)may be recorded for long-term storage and retrieval by a user, and/orused by processing circuitry 57 for adjustment of stimulation parameters(e.g., amplitude, pulse width, and pulse rate). In some examples, memory60 includes separate memories for storing instructions, electricalsignal information, and stimulation programs 63. In some examples,processing circuitry 57 may select new stimulation parameters for astimulation program 63 or new stimulation program from stimulationprograms 63 to use in the delivery of the electrical stimulation basedon patient input and/or monitored physiological states after terminationof the electrical stimulation.

Generally, therapy delivery circuitry 58 generates and deliverselectrical stimulation under the control of processing circuitry 57. Insome examples, processing circuitry 57 controls therapy deliverycircuitry 58 by accessing memory 60 to selectively access and load atleast one of stimulation programs 63 to therapy delivery circuitry 58.For example, in operation, processing circuitry 57 may access memory 60to load one of stimulation programs 63 to therapy delivery circuitry 58.

By way of example, processing circuitry 57 may access memory 60 to loadone of stimulation programs 63 to control therapy delivery circuitry 58for delivering the electrical stimulation to patient 14. A clinician orpatient 14 may select a particular one of stimulation programs 63 from alist using a programming device, such as a patient programmer or aclinician programmer. Processing circuitry 57 may receive the selectionvia telemetry circuitry 61. Therapy delivery circuitry 58 delivers theelectrical stimulation to patient 14 according to the selected programfor an extended period of time, such as minutes or hours while patient14 is asleep (e.g., as determined from the one or more sensors and/orsensing circuitry 56). For example, processing circuitry 57 may controlswitch circuitry 59 to couple electrodes 30 to therapy deliverycircuitry 58.

Therapy delivery circuitry 58 delivers electrical stimulation accordingto stimulation parameters. In some examples, therapy delivery circuitry58 delivers electrical stimulation in the form of electrical pulses. Insuch examples, relevant stimulation parameters may include a voltage orcurrent pulse amplitude, a pulse rate, a pulse width, a duty cycle,and/or the combination of electrodes 30 that therapy delivery circuitry58 uses to deliver the stimulation signal. In some examples, therapydelivery circuitry 58 delivers electrical stimulation in the form ofcontinuous waveforms. In such examples, relevant stimulation parametersmay include a voltage or current amplitude, a frequency, a shape of thestimulation signal, a duty cycle of the stimulation signal, or thecombination of electrodes 30 therapy delivery circuitry 58 uses todeliver the stimulation signal.

In some examples, the stimulation parameters for the stimulationprograms 63 may be selected to cause protrusor muscles 42 and/or 46 to aprotruded state (e.g., to open-up airway 48). An example range ofstimulation parameters for the electrical stimulation that are likely tobe effective in treating OSA (e.g., upon application to the hypoglossalnerves to cause protrusor muscles 42, 46 to protrude or upon applicationto motor points such as motor points 54A, 54B, 55A, and 55B), are asfollows:

-   -   a. Frequency or pulse rate: between about 30 Hz and about 50 Hz.        In some examples, the minimum target frequency is used which can        achieve muscle tetany (e.g., constant contraction) and provide        the required force to open the airway.    -   b. Current Amplitude: between about 0.5 milliamps (mA) and about        10 mA, and more generally from 0.5 mA to 3 mA, and approximately        1.5 mA.    -   c. Pulse Width: between about 100 microseconds (μs) and about        500 μs. In some examples, a pulse width of 150 μs might be used        for reduced power consumption. In some particular examples, the        pulse width is approximately 210 μs. In some cases, shorter        pulse widths may be used in conjunction with higher current or        voltage amplitudes.

Processing circuitry 57 may select stimulation programs 63 foralternating delivery of electrical stimulation between stimulating theleft protrusor muscles 42 and/or 46 and the right protrusor muscles 42and/or 46 on a time basis, such as in examples where two leads 20 areimplanted. In some examples, there may be some overlap in the deliveryof electrical stimulation such that for some of amount of time both leftand right protrusor muscles 42 and/or 46 are being stimulated. In someexamples, there may be a pause in alternating stimulation (e.g.,stimulate left protrusor muscles, a time period with no stimulation,then stimulate right protrusor muscles, and so forth). Processingcircuitry 57 may also select stimulation programs 63 that select betweendifferent combinations of electrodes 30 for stimulating, such as tostimulate different locations of the hypoglossal nerve(s), which mayhelp with fatigue as well as provide more granular control of how muchto protrude tongue 40.

In the example of FIG. 4, therapy delivery circuitry 58 driveselectrodes 30 of lead 20. Specifically, therapy delivery circuitry 58delivers electrical stimulation (e.g., regulated current or voltagepulses at pulse rates and pulse widths described above) to tissue ofpatient 14 via selected electrodes 30A-30D carried by lead 20. Aproximal end of lead 20 extends from the housing of IMD 16 and a distalend of lead 20 extends to a target therapy site, such as one or bothhypoglossal nerves and/or motor points 54A, 55A, 54B, and/or 55B.Therapy delivery circuitry 54 may deliver electrical stimulation withelectrodes on more than one lead and each of the leads may carry one ormore electrodes, such as when patient 14 is implanted with two leads 20in tongue 40 for stimulating both hypoglossal nerves simultaneously orbilaterally (e.g., one after the other) or both motor points 54A and 54Band/or motor points 55A and 55B. The leads may be configured as an axiallead with ring electrodes or segmented electrodes and/or paddle leadswith electrode pads arranged in a two-dimensional array. The electrodesmay operate in a bipolar or multi-polar configuration with otherelectrodes, or may operate in a unipolar configuration referenced to anelectrode carried by the device housing or “can” of IMD 16.

In some examples, processing circuitry 57 may control therapy deliverycircuitry 58 to deliver or terminate the electrical stimulation based onpatient input received via telemetry circuitry 61. Telemetry circuitry61 includes any suitable hardware, firmware, software or any combinationthereof for communicating with another device, such as an externalprogrammer. Under the control of processing circuitry 57, telemetrycircuitry 61 may receive downlink telemetry (e.g., patient input) fromand send uplink telemetry (e.g., an alert) to a programmer with the aidof an antenna, which may be internal and/or external. Processingcircuitry 57 may provide the data to be uplinked to the programmer andthe control signals for telemetry circuitry 61 and receive data fromtelemetry circuitry 61.

Generally, processing circuitry 57 controls telemetry circuitry 61 toexchange information with a medical device programmer and/or anotherdevice external to IMD 16. Processing circuitry 57 may transmitoperational information and receive stimulation programs or stimulationparameter adjustments via telemetry circuitry 61. Also, in someexamples, IMD 16 may communicate with other implanted devices, such asstimulators, control devices, or sensors, via telemetry circuitry 61.

Power source 62 delivers operating power to the components of IMD 16.Power source 62 may include a battery and a power generation circuit toproduce the operating power. In some examples, the battery may berechargeable to allow extended operation. Recharging may be accomplishedthrough proximal inductive interaction between an external charger andan inductive charging coil within IMD 16. In other examples, an externalinductive power supply may transcutaneously power IMD 16 wheneverelectrical stimulation is to occur.

FIG. 5 is a block diagram illustrating an example configuration of anexternal programmer 70. While programmer 70 may generally be describedas a hand-held computing device, the programmer may be a notebookcomputer, a cell phone, or a workstation, for example. As illustrated inFIG. 5, external programmer 70 may include processing circuitry 72,memory 74, user interface 76, telemetry circuitry 78, and power source80.

In general, programmer 70 comprises any suitable arrangement ofhardware, alone or in combination with software and/or firmware, toperform the techniques attributed to programmer 70, and processingcircuitry 72, user interface 76, and telemetry module 78 of programmer70. Examples of processing circuitry 72 may include one or moreprocessors, such as one or more microprocessors, DSPs, ASICs, FPGAs, orany other equivalent integrated or discrete logic circuitry, as well asany combinations of such components. Examples of memory 74 include RAM,ROM, PROM, EPROM, EEPROM, flash memory, a hard disk, a CD-ROM,comprising executable instructions for causing the one or moreprocessors to perform the actions attributed to them. Moreover, althoughprocessing circuitry 72 and telemetry circuitry 78 are described asseparate circuitry, in some examples, processing circuitry 72 andtelemetry circuitry 78 are functionally integrated. In some examples,processing circuitry 72 and telemetry circuitry 78 correspond toindividual hardware units, such as ASICs, DSPs, FPGAs, or other hardwareunits.

In some examples, memory 74 may further include program information(e.g., stimulation programs) defining the electrical stimulation,similar to those stored in memory 60 of IMD 16. The stimulation programsstored in memory 74 may be downloaded into memory 60 of IMD 16.

User interface 76 may include a button or keypad, lights, a speaker forvoice commands, a display, such as a liquid crystal (LCD),light-emitting diode (LED), or cathode ray tube (CRT). In some examplesthe display may be a touch screen. As discussed in this disclosure,processing circuitry 72 may present and receive information relating toelectrical stimulation and resulting therapeutic effects via userinterface 76. For example, processing circuitry 72 may receive patientinput via user interface 76. The input may be, for example, in the formof pressing a button on a keypad or selecting an icon from a touchscreen.

Processing circuitry 72 may also present information to the patient inthe form of alerts related to delivery of the electrical stimulation topatient 14 or a caregiver via user interface 76. Although not shown,programmer 70 may additionally or alternatively include a data ornetwork interface to another computing device, to facilitatecommunication with the other device, and presentation of informationrelating to the electrical stimulation and therapeutic effects aftertermination of the electrical stimulation via the other device.

Telemetry circuitry 78 supports wireless communication between IMD 16and programmer 70 under the control of processing circuitry 72.Telemetry circuitry 78 may also be configured to communicate withanother computing device via wireless communication techniques, ordirect communication through a wired connection. In some examples,telemetry circuitry 78 may be substantially similar to telemetrycircuitry 61 of IMD 16 described above, providing wireless communicationvia an RF or proximal inductive medium. In some examples, telemetrycircuitry 78 may include an antenna, which may take on a variety offorms, such as an internal or external antenna.

Examples of local wireless communication techniques that may be employedto facilitate communication between programmer 70 and another computingdevice include RF communication according to the 802.11 or Bluetoothspecification sets, infrared communication (e.g., according to the IrDAstandard), or other standard or proprietary telemetry protocols. In thismanner, other external devices may be capable of communicating withprogrammer 70 without needing to establish a secure wireless connection.

Power source 80 delivers operating power to the components of programmer70. Power source 80 may include a battery and a power generation circuitto produce the operating power. In some examples, the battery may berechargeable to allow extended operation.

FIG. 6A-6C are conceptual diagrams illustrating a lead and an exampleintroducer needle which may be utilized in the system of FIG. 1. FIG. 6Aillustrates an example of lead 90 that includes electrodes 98A and 98Bat a distal end of the lead. FIG. 6B illustrates an example ofintroducer needle 110 formed from a conducting material, where theintroducer needle includes an insulation coating that defines one ormore electrically conductive areas. FIG. 6C illustrates the insertion ofthe lead 90 in the introducer needle 110. Lead 90 may be similar to lead20 but may include fewer than the four electrodes 30, such as twoelectrodes 98A, 98B.

In the example illustrated in FIG. 6B, introducer needle 110 includes anelongated body 114 and an insulation coating 116. Introducer needle 110is an example of the introducer needle described above for creating anopening in tongue 40 for lead placement of lead 20 or lead 90. Thefollowing is described with respect to lead 90, but the examples areapplicable to lead 20 as well.

Elongated body 114 of introducer needle 110 is formed from any suitableconducting material, such as, but not limited to, stainless steel,cobalt-chrome alloy, titanium, nickel-titanium alloy (nitinol), gold,platinum, silver, iridium, tantalum, tungsten, or the like. Elongatedbody 114 includes a lumen 120, so that lead 90 may be inserted in lumen120 of elongated body 114.

Insulation coating 116 includes openings 117A and 117B at a distal end118 of elongated body 114, which defines electrically conductive areas112A and 112B. Insulation coating 116 may be formed from any suitablenon-conducting material, such as vinyl, silicone, vinyl-silicone,polyurethane, or a composite of aluminum oxide/boron nitride (AOBN),polyvinylidene fluoride, polyethylene, polypropylene,polydimethylsiloxane, perylene, polyamide, polytetrafluoroethylene,polymethylmethacrylate, polyimide, polyurethane, liquid crystallinepolymers, nanocomposites, or the like. Openings 117A and 117B ofinsulation coating 116 may be formed by any suitable technique. In someexamples, openings 117A and 117B are formed by a mechanical technique,such as, but not limited to, laser cutting, drilling, or punching. Inother examples, openings 117A and 117B are formed by a chemicaltechnique, such, but not limited to, the selective dissolution of one ormore sections of the insulation coating 116, or any combination thereof.In some examples, there may be a 1 mm spacing between openings 117A and117B, and “at distal end 118” includes examples where openings 117A and117B are proximate to distal end 118.

Introducer needle 110 may operate in a unipolar configuration (e.g., aunipolar needle electrode) to stimulate a hypoglossal nerve and/or amotor point (e.g., one or more of motor points 54A, 54B, 55A, or 55B) inthe tongue of a patient. For example, a surgeon may guide distal end 118of elongated body 114 to a location proximal to the hypoglossal nerveand/or the motor point (e.g., one or more of motor points 54A, 54B, 55A,or 55B) and deliver stimulation signals through electrically conductiveareas 112A and 112B of introducer needle 110 to the hypoglossal nerveand/or the motor point. In such cases, introducer needle 110 is coupledto a return electrode (e.g., a ground pad), where the return electrodeis secured to the patient's skin. In some examples, electricallyconductive areas 112A and 112B may be electrically isolated fromanother, and in such examples, one of electrically conductive areas 112Aand 112B may be used to output the stimulation signals and the other ofelectrically conductive areas 112A and 112B may provide the return path.

The stimulation signals delivered to the hypoglossal nerve and/or themotor point (e.g., one or more of motor points 54A, 54B, 55A, or 55B)may cause a muscle contraction of a protrusor muscle, which may generateelectrical signals. The electrical signals generated during the musclecontraction may be detected at electrically conductive areas 112A and112B by introducer needle 110. The surgeon may control the medicaldevice to receive the electrical signals and output informationindicative of the one or more electrical signals on a display device.The surgeon may then determine a target treatment site based on theoutput information. In some examples, reception of electrical signalsmay not be necessary and visual inspection to determine if tongue 40protruded or if protrusor muscles 42 and/or 46 activated may besufficient.

In the example illustrated in FIG. 6C, after the target treatment siteis determined, the surgeon may insert lead 90 in lumen 120 of introducerneedle 110. As described in more detail, in some examples, rather thaninserting lead 90 into lumen 120 of introducer needle 110, needle 110may be removed and an introducer sheath is placed in the opening createdby needle 110. Lead 90 is placed in the lumen of the introducer sheath.

As illustrated in FIG. 6C, electrodes 98A and 98B of lead 90 are alignedwith electrically conductive areas 112A and 112B of the introducerneedle 110 along a vertical axial A-A. The surgeon may then control themedical device to deliver a stimulation signal via electrodes 98A and98B of lead 90 through electrically conductive areas 112A and 112B ofthe introducer needle 110 to the tongue of the patient to stimulate thehypoglossal nerve and/or the motor point (e.g., one or more of motorpoints 54A, 54B, 55A, or 55B) in the tongue of the patient. In this way,introducer needle 110 does not have to be withdrawn to expose electrodes98A and 98B for testing to ensure that lead 90 is properly placed. Insome examples, a first medical device may be used to provide stimulationto electrically conductive areas 112A, 112B and a second medical devicemay be used to provide stimulation to electrodes 98A and 98B after lead90 is inserted into lumen 120. In some examples, the first medicaldevice and the second medical device may be the same medical device.

FIG. 7A-7C are conceptual diagrams illustrating the lead of FIG. 6A andanother example introducer needle which may be utilized in the system ofFIG. 1. Similar to FIG. 6A and reproduced for ease of understanding,FIG. 7A illustrates an example of lead 90 that includes electrodes 98Aand 98B at a distal end of the lead. FIG. 7B illustrates an example ofintroducer needle 130 formed from a semiconducting material, where theintroducer needle includes one or more electrode interfaces located atone or more electrically conductive areas. FIG. 7C illustrates theinsertion of the lead in the introducer needle.

In the example illustrated in FIG. 7B, introducer needle 130 includes anelongated body 134 and electrode interfaces 136A and 136B. Elongatedbody 134 of introducer needle 130 is formed from any suitablesemiconducting material, such as, but not limited to, germanium,selenium, silicon, or the like.

Electrode interfaces 136A and 136B are located at electricallyconductive areas 112A and 112B at a distal end 138 of elongated body134. In some examples, electrode interfaces 136A and 136B each includean electrode attached to the outer perimeter of elongated body 134 ofintroducer needle 130. In this way, introducer needle 130 may operate ina bipolar or multi-polar configuration with other electrode interfacesreferenced to an electrode carried by the medical device (e.g., IMD 16).For example, one of electrode interfaces 136A and 136B may be used todeliver stimulation and the other one of electrode interfaces 136A and136B may be used to provide a return path for the stimulation.

In the example illustrated in FIG. 7C, when lead 90 is inserted in lumen140 of introducer needle 130, electrodes 98A and 98B of lead 90 arealigned with electrically conductive areas 132A and 132B of theintroducer needle along a vertical axial B-B. After insertion of lead 90in lumen 130 of introducer needle 130, the surgeon can control themedical device to deliver a stimulation signal via electrodes 98A and98B of lead 90 through electrically conductive areas 132A and 132B ofthe introducer needle 130 to the tongue 40 of the patient to stimulatethe hypoglossal nerve and/or the motor point (e.g., one or more of motorpoints 54A, 54B, 55A, or 55B). In this way, introducer needle 130 doesnot have to be withdrawn to expose electrodes 98A and 98B for testing toensure that lead 90 is properly placed.

FIG. 8A-8D are conceptual diagrams illustrating another example lead 2,another example introducer needle, and an example introducer sheathwhich may be utilized in the system of FIG. 1. FIG. 8A illustrates anexample of lead 150 that includes one or more electrodes 158 (for easeonly electrode 158 is shown in FIG. 8A) at a distal end of the lead.FIG. 8B illustrates an example of introducer needle 160 that is similarto introducer needle 110 shown in FIG. 6B or introducer needle 130 shownin FIG. 7B. FIG. 8C illustrates an example of an introducer sheath 180that includes perforations 188 (for ease only perforation 188 is shownin FIG. 8C) at a distal end of the introducer sheath. FIG. 8Dillustrates the insertion of lead 150 in introducer sheath 180.

In some examples, lead 150 may have a relatively large diameter. Forexample, lead 150 may be a multi-polar lead that includes multipleelectrodes attached to an outer perimeter of lead 150. For example,electrode 158 may include four electrodes circumstantially spaced fromeach other about the outer perimeter of lead 150.

There may be certain unique challenges associated with implanting a leadwith a relatively large diameter. As an example, lead 150 may have adiameter equal to or larger than the diameter of introducer needle 160so that lead 150 may not be inserted in lumen 170 of elongated body 164.

In some cases, rather than lead 150 being considered as having a largediameter, needle 160 may be considered as having a relatively smalldiameter. For instance, to minimize the size of the opening, needle 160may be sized to have a relatively small diameter.

To place lead 150 within an opening created by introducer needle 160, aguidewire 165 and an introducer sheath 180 may be used to help insertionof lead 160 through tissue near a chin of a patient and through a tongueof the patient.

In the example illustrated in FIG. 8B, introducer needle 160 includes anelongated body 164 and one or more electrically conductive areas 162(for ease only electrically conductive area 162 is shown in FIG. 8B)around a distal end of introducer needle 160. Elongated body 164 has alumen 170 so that a surgeon may insert a guidewire 165 in lumen 170 ofthe elongated body. After guidewire 165 is placed in lumen 170 ofelongated body 164, the surgeon may retract introducer needle 160 whileleaving guidewire 165 in the tongue of the patient.

In the example illustrated in FIG. 8C, an introducer sheath 180 may beslide over guidewire 165 to reach a hypoglossal nerve and/or a motorpoint in the tongue of the patient.

Introducer sheath 180 is formed from any suitable material, such as, butnot limited to, high density polyethylene, polytetrafluoroethylene,low-density polyethylene, or any combination thereof. Introducer sheath180 includes a lumen 190, so that lead 150 may be inserted in lumen 190of the introducer sheath.

Introducer sheath 180 further includes one or more perforations 188 (forease only perforation 188 is shown in FIG. 8C) at a distal end 118 ofIntroducer sheath 180. In the examples illustrated in FIGS. 8B and 8C,perforation 188 of introducer sheath 180 is aligned with electricallyconductive area 162 of introducer needle 160 along a vertical axial C-C.

Perforation 188 may be formed by any suitable technique. In someexamples, perforation 188 is formed by a mechanical technique, such as,but not limited to, laser cutting, drilling, or punching. In otherexamples, perforation 188 is formed by a chemical technique, such, butnot limited to, the selective dissolution of one or more sections of theintroducer sheath 180, or any combination thereof.

In some examples, introducer sheath 180 may be coupled with a dilator tofacilitate advancement of introducer sheath 180 into and through theopening created by introducer needle 160 so that introducer sheath 180can be advanced along guidewire 165 to the hypoglossal nerve and/or themotor point (e.g., one or more of motor points 54A, 54B, 55A, or 55B).After guidewire 165 is placed in lumen 190 of introducer sheath 180, thesurgeon may remove guidewire 165 and insert lead 150 in lumen 190 ofintroducer sheath 180.

In the example illustrated in FIG. 8D, perforation 188 of introducersheath 180 is also aligned with electrode 158 of lead 150 along thevertical axial C-C. The surgeon may then control the medical device todeliver a stimulation signal via electrode 158 of lead 150 throughperforations 188 of introducer sheath 180 to the tongue of the patientto stimulate the hypoglossal nerve and/or the motor point. In this way,lead 150 with a diameter equal to or larger than the diameter ofintroducer needle 160 may be advanced into and through the openingcreated by introducer needle 160.

FIG. 9 is a flowchart illustrating an example of lead implantation. Amedical professional may insert an introducer needle (e.g., introducerneedle 110, 130, or 160) through tissue near a chin of patient 14 andthrough tongue 40 of patient 14 (220). The introducer needle may includean elongated body having one or more electrically conductive areas forcreating an opening in a tongue of a patient for implantation of a leadfor treating OSA. The medical professional may control a medical device(e.g., IMD 16) to deliver a first stimulation signal via the introducerneedle through the one or more electrically conductive areas to tongue40 of patient 14 to stimulate a hypoglossal nerve and/or a motor (e.g.,one or more of motor points 54A, 54B, 55A, or 55B) point (222).

In some examples, the medical professional may control the medicaldevice to receive a first set of electrical signals detected by one ormore of the electrically conductive areas of the introducer needle andoutput information indicative of the first set of electrical signals(224). The medical professional may then determine a target treatmentsite based on the output information indicative of the first set ofelectrical signals (226).

In some examples, the medical professional may insert a lead (e.g., lead20 or lead 90) into the introducer needle (228), remove the introducerneedle (230), and control the medical device to deliver a first set ofstimulation signals via the lead through the one or more electricallyconductive areas of the introducer needle to the tongue of the patientto stimulate the hypoglossal nerve and/or the motor point (e.g., one ormore of motor points 54A, 54B, 55A, or 55B) in the tongue of the patient(232). As described above, one or more electrodes of the lead align withthe one or more electrically conductive areas of the introducer needle.For example, electrodes 98A and 98B of lead 90 align with electricallyconductive areas 112A and 112B of introducer needle 110.

FIG. 10 is another flowchart illustrating an example of leadimplantation. A medical professional may insert an introducer needle(e.g., introducer needle 110, 130, or 160) through tissue near a chin ofpatient 14 and through tongue 40 of patient 14 (320). The introducerneedle may include an elongated body having one or more electricallyconductive areas for creating an opening in a tongue of a patient forimplantation of a lead for treating OSA. The medical professional maycontrol a first medical device (e.g., IMD 16) to deliver a firststimulation signal via the introducer needle through the one or moreelectrically conductive areas to tongue 40 of patient 14 to stimulate ahypoglossal nerve and/or a motor point (e.g., one or more of motorpoints 54A, 54B, 55A, or 55B) (322).

In some examples, the medical professional may control the first medicaldevice to receive a first set of electrical signals detected by one ormore of the electrically conductive areas of the introducer needle andoutput information indicative of the first set of electrical signals(324). The medical professional may then determine a target treatmentsite based on the output information indicative of the first set ofelectrical signals (326).

In some examples, the medical professional may insert a guidewire (e.g.,guidewire 165) into the introducer needle (328), remove the introducerneedle (330), slide an introducer sheath (e.g., introducer sheath 180)over the guidewire (332), and remove the guidewire (334).

In some examples, the medical professional may insert a lead (e.g., lead20, 90, or 150) into the introducer sheath (336), remove the introducersheath (338), and control a second medical device to deliver a secondset of stimulation signals via the lead through the one or moreelectrically conductive areas of the introducer needle to the tongue ofthe patient to stimulate the hypoglossal nerve and/or the motor point(e.g., one or more of motor points 54A, 54B, 55A, or 55B) in the tongueof the patient (340). As described above, in some examples, the firstmedical device and the second medical device may be different medicaldevices. In other examples, the first medical device and the secondmedical device may be the same medical device. One or more perforationsof the introducer sheath are aligned with the one or more electricallyconductive areas of the introducer needle. For example, perforation 188of introducer sheath 180 is aligned with electrically conductive area162 of introducer needle 160. The one or more perforations of theintroducer sheath are further aligned with the one or more electrodes ofthe lead. For example, perforation 188 of introducer sheath 180 isaligned with electrode 158 of lead 150.

It should be noted that system 10, and the techniques described herein,may not be limited to treatment or monitoring of a human patient. Inalternative examples, system 10 may be implemented in non-humanpatients, e.g., primates, canines, equines, pigs, and felines. Theseother animals may undergo clinical or research therapies that my benefitfrom the subject matter of this disclosure. Various examples aredescribed herein, such as the following examples.

Example 1. A system for treatment of obstructive sleep apnea (OSA), thesystem comprising: an introducer needle comprising an elongated bodyhaving one or more electrically conductive areas for creating an openingin a tongue of a patient for implantation of a lead for treating OSA;and a medical device configured to deliver a stimulation signal via theintroducer needle through the one or more electrically conductive areasto the tongue of the patient to stimulate one or more motor points of aprotrusor muscle within the tongue of the patient.

Example 2. The system of example 1, wherein the medical device isconfigured to receive one or more electrical signals detected by the oneor more of the electrically conductive areas of the introducer needleand output information indicative of the one or more electrical signals.

Example 3. The system of example 2, wherein the one or more electricalsignals include an electromyography (EMG) signal.

Example 4. The system of any of examples 1-3, wherein the one or moreelectrically conductive areas are located at a distal end of theintroducer needle.

Example 5. The system of any of examples 1-4, wherein the one or moreelectrically conductive areas comprises less than four electricallyconductive areas.

Example 6. The system of any of examples 1-5, wherein the introducerneedle is formed from a semiconducting material, the introducer needlecomprises one or more electrode interfaces, wherein the one or moreelectrode interfaces are located at the one or more electricallyconductive areas.

Example 7. The system of any of examples 1-5, wherein the introducerneedle is formed from a conducting material, the introducer needlecomprises an insulation coating, wherein the insulation coating definesthe one or more electrically conductive areas.

Example 8. The system of any of examples 1-7, wherein one or moreelectrodes of the lead are aligned with the one or more electricallyconductive areas of the introducer needle.

Example 9. The system of any of examples 1-8, the medical device isfurther configured to deliver a first set of stimulation signals via oneor more electrodes of the lead through the one or more electricallyconductive areas of the introducer needle to the tongue of the patientto stimulate the one or more motor points of the protrusor muscle withinthe tongue of the patient.

Example 10. The system of any of examples 1-9, further comprising: anintroducer sheath, wherein the introducer sheath is configured to beplaced within the opening created by the introducer needle, wherein theintroducer sheath comprises one or more perforations.

Example 11. The system of example 10, wherein the one or moreperforations of the introducer sheath align with the one or moreelectrically conductive areas of the introducer needle.

Example 12. The system of any of examples 10-11, wherein the one or moreperforations of the introducer sheath align with the one or moreelectrodes of the lead.

Example 13. The system of any of examples 10-12, the medical device isfurther configured to deliver a second set of stimulation signals viathe one or more electrodes of the lead through the one or moreperforations of the introducer sheath to the tongue of the patient tostimulate the one or more motor points of the protrusor muscle withinthe tongue of the patient.

Example 14. A system for treatment of obstructive sleep apnea (OSA), thesystem comprising: an introducer needle comprising an elongated bodyhaving one or more electrically conductive areas for creating an openingin a tongue of a patient for implantation of a lead for treating OSA; anintroducer sheath configured to be placed within the opening created bythe introducer needle, wherein the introducer sheath comprises one ormore perforations that align with one or more electrodes of a leadinserted into the introducer sheath; and one or more medical devices areconfigured to deliver a stimulation signal via the introducer needlethrough the one or more electrically conductive areas to the tongue ofthe patient to stimulate one or more motor points of a protrusor musclewithin the tongue of the patient, wherein the one or more medicaldevices are further configured to deliver the stimulation signal withthe one or more electrodes of the lead that is inserted into theintroducer sheath and through the one or more perforations of theintroducer sheath to the tongue of the patient.

Example 15. The system of example 14, wherein the one or more medicaldevices are configured to receive one or more electrical signalsdetected by the one or more of the electrically conductive areas of theintroducer needle and output information indicative of the one or moreelectrical signals.

Example 16. The system of example 15, wherein the one or more electricalsignals include an electromyography (EMG) signal.

Example 17. The system of any of examples 14-16, wherein the one or moreelectrically conductive areas are located at a distal end of theintroducer needle.

Example 18. The system of any of examples 14-17, wherein the one or moreelectrically conductive areas comprises less than four electricallyconductive areas.

Example 19. The system of any of examples 14-18, wherein the introducerneedle is formed from a semiconducting material, the introducer needlecomprises one or more electrode interfaces, wherein the one or moreelectrode interfaces are located at the one or more electricallyconductive areas.

Example 20. The system of any of examples 14-18, wherein the introducerneedle is formed from a conducting material, the introducer needlecomprises an insulation coating, wherein the insulation coating definesthe one or more electrically conductive areas.

Example 21. The system of any of examples 14-20, wherein one or moreelectrodes of the lead are aligned with the one or more electricallyconductive areas of the introducer needle.

Example 22. The system of any of examples 14-11, wherein the one or moreperforations of the introducer sheath align with one or more electrodesof the lead.

Example 23. A method for treatment of obstructive sleep apnea (OSA), themethod comprising: inserting an introducer needle through tissue near achin of a patient and through a tongue of the patient, wherein theintroducer needle comprises an elongated body having one or moreelectrically conductive areas, wherein the introducer needle is forcreating an opening in the tongue of the patient for implantation of alead for treating OSA; and controlling a medical device to deliver astimulation signal via the introducer needle through the one or moreelectrically conductive areas to the tongue of the patient to stimulateone or more motor points of a protrusor muscle within the tongue of thepatient.

Example 24. The method of example 23, further comprising: inserting thelead into the introducer needle, wherein the one or more electrodes ofthe lead align with the one or more electrically conductive areas of theintroducer needle; removing the introducer needle; and controlling themedical device to deliver a first set of stimulation signals via thelead through the one or more electrically conductive areas of theintroducer needle to the tongue of the patient to stimulate the one ormore motor points of the protrusor muscle within the tongue of thepatient.

Example 25. The method of any of examples 23 and 24, further comprising:inserting the lead into an introducer sheath, wherein the introducersheath comprises one or more perforations, wherein the one or moreperforations align with the one or more electrically conductive areas ofthe introducer needle, wherein the one or more perforations of theintroducer sheath align with the one or more electrodes of the lead;removing the introducer sheath; and controlling the medical device todeliver a second set of stimulation signals via the lead through the oneor more perforations of the introducer sheath to the tongue of thepatient to stimulate the one or more motor points of the protrusormuscle within the tongue of the patient.

The techniques of this disclosure may be implemented in a wide varietyof computing devices, medical devices, or any combination thereof. Anyof the described units, modules or components may be implementedtogether or separately as discrete but interoperable logic devices.Depiction of different features as modules or units is intended tohighlight different functional aspects and does not necessarily implythat such modules or units must be realized by separate hardware orsoftware components. Rather, functionality associated with one or moremodules or units may be performed by separate hardware or softwarecomponents, or integrated within common or separate hardware or softwarecomponents.

The disclosure contemplates computer-readable storage media comprisinginstructions to cause a processor to perform any of the functions andtechniques described herein. The computer-readable storage media maytake the example form of any volatile, non-volatile, magnetic, optical,or electrical media, such as a RAM, ROM, NVRAM, EEPROM, or flash memorythat is tangible. The computer-readable storage media may be referred toas non-transitory. A server, client computing device, or any othercomputing device may also contain a more portable removable memory typeto enable easy data transfer or offline data analysis.

The techniques described in this disclosure, including those attributedto various modules and various constituent components, may beimplemented, at least in part, in hardware, software, firmware or anycombination thereof. For example, various aspects of the techniques maybe implemented within one or more processors, including one or moremicroprocessors, DSPs, ASICs, FPGAs, or any other equivalent integrated,discrete logic circuitry, or other processing circuitry, as well as anycombinations of such components, remote servers, remote client devices,or other devices. The term “processor” or “processing circuitry” maygenerally refer to any of the foregoing logic circuitry, alone or incombination with other logic circuitry, or any other equivalentcircuitry.

Such hardware, software, firmware may be implemented within the samedevice or within separate devices to support the various operations andfunctions described in this disclosure. In addition, any of thedescribed units, modules or components may be implemented together orseparately as discrete but interoperable logic devices. Depiction ofdifferent features as modules or units is intended to highlightdifferent functional aspects and does not necessarily imply that suchmodules or units must be realized by separate hardware or softwarecomponents. Rather, functionality associated with one or more modules orunits may be performed by separate hardware or software components, orintegrated within common or separate hardware or software components.For example, any module described herein may include electricalcircuitry configured to perform the features attributed to thatparticular module, such as fixed function processing circuitry,programmable processing circuitry, or combinations thereof.

The techniques described in this disclosure may also be embodied orencoded in an article of manufacture including a computer-readablestorage medium encoded with instructions. Instructions embedded orencoded in an article of manufacture including a computer-readablestorage medium encoded, may cause one or more programmable processors,or other processors, to implement one or more of the techniquesdescribed herein, such as when instructions included or encoded in thecomputer-readable storage medium are executed by the one or moreprocessors. Example computer-readable storage media may include randomaccess memory (RAM), read only memory (ROM), programmable read onlymemory (PROM), erasable programmable read only memory (EPROM),electronically erasable programmable read only memory (EEPROM), flashmemory, a hard disk, a compact disc ROM (CD-ROM), a floppy disk, acassette, magnetic media, optical media, or any other computer readablestorage devices or tangible computer readable media. Thecomputer-readable storage medium may also be referred to as storagedevices.

In some examples, a computer-readable storage medium comprisesnon-transitory medium. The term “non-transitory” may indicate that thestorage medium is not embodied in a carrier wave or a propagated signal.In certain examples, a non-transitory storage medium may store data thatcan, over time, change (e.g., in RAM or cache).

Various examples have been described herein. Any combination of thedescribed operations or functions is contemplated. These and otherexamples are within the scope of the following claims.

What is claimed is:
 1. A method for treatment of obstructive sleep apnea(OSA), the method comprising: inserting an introducer needle throughtissue near a chin of a patient and through a tongue of the patient,wherein the introducer needle comprises an elongated body having one ormore electrically conductive areas, wherein the introducer needle is forcreating an opening in the tongue of the patient for implantation of alead for treating OSA; and controlling a medical device to deliver astimulation signal via the introducer needle through the one or moreelectrically conductive areas to the tongue of the patient to stimulateone or more motor points of a protrusor muscle within the tongue of thepatient.
 2. The method of claim 1, further comprising: inserting thelead into the introducer needle, wherein the one or more electrodes ofthe lead align with the one or more electrically conductive areas of theintroducer needle; removing the introducer needle; and controlling themedical device to deliver a first set of stimulation signals via thelead through the one or more electrically conductive areas of theintroducer needle to the tongue of the patient to stimulate the one ormore motor points of the protrusor muscle within the tongue of thepatient.
 3. The method of claim 1, further comprising: inserting thelead into an introducer sheath, wherein the introducer sheath comprisesone or more perforations, wherein the one or more perforations alignwith the one or more electrically conductive areas of the introducerneedle, wherein the one or more perforations of the introducer sheathalign with the one or more electrodes of the lead; removing theintroducer sheath; and controlling the medical device to deliver asecond set of stimulation signals via the lead through the one or moreperforations of the introducer sheath to the tongue of the patient tostimulate the one or more motor points of the protrusor muscle withinthe tongue of the patient.